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Abstract

Background

Rural residents are increasingly identified as being at greater risk for health disparities.
These inequities may be related to health behaviors such as adequate fruits and vegetable
consumption. There is little national-level population-based research about the prevalence
of fruit and vegetable consumption by US rural population adults. The objective of
this study was to examine the prevalence differences between US rural and non-rural
adults in consuming at least five daily servings of combined fruits and vegetables.

Methods

Cross-sectional analysis of weighted 2009 Behavioral Risk Factor Surveillance Survey
(BRFSS) data using bivariate and multivariate techniques. 52,259,789 US adults were
identified as consuming at least five daily servings of fruits and vegetables of which
8,983,840 were identified as living in rural locales.

Results

Bivariate analysis revealed that in comparison to non-rural US adults, rural adults
were less likely to consume five or more daily servings of fruits and vegetables (OR = 1.161,
95% CI 1.160-1.162). Logistic regression analysis revealed that US rural adults consuming
at least five daily servings of fruits and vegetables were more likely to be female,
non-Caucasian, married or living with a partner, living in a household without children,
living in a household whose annual income was

>

$35,000, and getting at least moderate physical activity. They were also more likely
to have a BMI of <30, have a personal physician, have had a routine medical exam in
the past 12 months, self-defined their health as good to excellent and to have deferred
medical care because of cost. When comparing the prevalence differences between rural
and non-rural US adults within a state, 37 States had a lower prevalence of rural
adults consuming at least five daily servings of fruits and vegetables and 11 States
a higher prevalence of the same.

Conclusions

This enhanced understanding of fruit and vegetable consumption should prove useful
to those seeking to lessen the disparity or inequity between rural and non-rural adults.
Additionally, those responsible for health-related planning could benefit from the
knowledge of how their state ranks in comparison to others vis-à-vis the consumption
of fruits and vegetables by rural adults---a population increasingly being identified
as one at risk for health disparities.

Keywords:

Rural health; Fruit and vegetable consumption; Adult nutrition; BRFSS

Background

Similar to the US Healthy People 2000 (HP 2000) and HP 2010 objectives, Healthy People
2020 (HP2020) [1] contains nutrition related objectives that recommend Americans increase their consumption
of both fruits and vegetables [2]. The HP 2020 objectives for fruit and vegetable consumption echo the 2010 Dietary
Guidelines for Americans that recommend an increase in vegetable and fruit intake
for all Americans aged 2 years and older [2]. Furthermore, the newly released guidelines emphasize the importance of consuming
a variety of vegetables (i.e. dark-green, red, orange vegetables) and beans and peas
[2]. Increasing the consumption of fruits and vegetables is deemed an important public
health issue since adequate fruit and vegetable consumption may reduce the risk for
several major causes of morbidity and mortality in the U.S. including type 2 diabetes
[3], heart disease [4,5], stroke [6] and obesity [7]. Moreover, research also suggests that diets rich in fruits and vegetables are associated
with a lower incidence of several cancers [8,9], suggesting that dietary choice is also an important cancer prevention measure [10-12].

In addition to reducing the risk of developing many chronic diseases, there is an
increasing and compelling body of clinical evidence supporting the benefit of diet
and physical activity in not only health maintenance and disease prevention but also
for disease treatment, a process referred to as Medical Nutrition Therapy (MNT) [13]. MNT is an essential component in the management and treatment of conditions such
as type 2 diabetes, heart disease, hyperlipidemia, stroke and obesity [14-16]. Several widely disseminated clinical practice guidelines advise eating diets high
in whole foods such as fruit, vegetables, and whole grains along with limiting animal
protein and avoiding high energy low nutrient foods as an important component of disease
management.

Another key HP2020 objective is to identify and track segments of the US population
experiencing health inequities with the goal of eliminating disparities. Individuals
living in rural settings are one population increasingly being identified as at risk
for health disparities [1,17-19]. Health inequities or disparities are differences in health between societal strata
or groups that are not only avoidable but that are also unnecessary, unfair and unjust
[20]. Rural populations in the US experience a disproportionate burden of a number of
chronic conditions and many of the major public health problems in rural areas such
as obesity, diabetes and tobacco use require or at the very least call for population-level
prevention-based interventions.

Hartley [17] urges researchers who have undertaken the examination of the health of rural Americans
to explore why rural residency including culture, community and environment, reinforce
negative health behaviors. Other researchers [19] aver that examining how and if rural residency affects health behaviors are equally
important and that focusing on such may identify rural residency as a fundamental
social cause [21] of health inequities.

While researchers have identified differences in fruit and vegetable intake related
to race and ethnicity [22-24], age [25,26], socioeconomic factors [22,27,28] and sex [25,29], there is little population-based, national level research examining the consumption
of fruits and vegetables by rural populations in the United States. Those studies
we found investigating the fruit and vegetable intake of rural populations were limited
because they either focused on regional or narrowly defined US populations (e.g.,
only Hispanic and African American groups or older rural adults) or rural settings
outside the US [30-32]

Ultimately focusing on US adults living in rural areas acknowledges the importance
of place in social epidemiology and public health concerns [33]. Specifically, when assessing health status, health service utilization, health service
deficits, adequacy of health care, and health related behaviors---place or geography
matters. It has long been held that the places where people live, work and play either
protect and/or promote their health and contribute to the health risks they experience
[34]. Previous research has indicated that rural residency is an independent risk factor
for obesity [35,36], diabetes [37,38], and cardiovascular disease [37] suggesting that dietary habits such as the consumption of fruits and vegetables by
rural individuals may differ from their non-rural counterparts.

This study examined the prevalence differences between US rural and non-rural adults
in the consumption of at least five daily servings of combined fruits and vegetables.
In addition, this study explored what characteristics if any were associated with
rural adults consuming five fruits and/or vegetable servings daily. Finally, this
study examined by State the prevalence differences between rural and non-rural adult
consumption of at least five daily servings of fruits and vegetables.

Methods

Data source

Data from the 2009 Behavioral Risk Factor Surveillance Survey (BRFSS), were examined
to determine if there were disparities and/or differences between rural and non-rural
adults in regard to the daily consumption of at least five servings of combined fruits
and vegetables. BRFSS is a cross-sectional, random digit telephone survey that is
a collaborative project of the Centers for Disease Control and Prevention (CDC) and
all US states and territories. The survey measures several behavioral risk factors
in the adult population aged 18 years and older. Its objective is to collect uniform,
state-specific data on preventive health practices and risk behaviors linked to chronic
diseases, injuries and preventable infectious diseases in the non-institutionalized
adult US population.

In this survey, data are collected from a random sample of adults (one per household).
All BRFSS data are self-reported responses to mostly forced-choice questions. No additional
data are generated to corroborate or substantiate the self-reported responses. As
recommended by the CDC, all analyses were performed on weighted data. The weighting
provides a stratified representation of the US adult non-institutionalized population
that conforms to census data. A more detailed description of the sampling methodology
of BRFSS is available elsewhere [39].

Defining rurality

While there are multiple ways of defining rural for both research as well as policy
purposes [40-44], deciding on the specific definition of rural to apply or adopt depends on the purpose
of the study, the data used in the analyses, and the appropriate and available taxonomy
[42]. Ultimately, there is no perfect definition of rural [42]. In the analyses conducted here, the Metropolitan Statistical Area (MSA) variable
included in BRFSS was used to define place of residence as either rural or non-rural.
This was the only variable available in the dataset that could be used to define rural
or geographical place of residency. As such rural residents were defined as persons
living either within an MSA that had no city center or outside an MSA. Non-rural residents
included all respondents living in a city center of an MSA, outside the city center
of an MSA but inside the county containing the city center, or inside a suburban county
of the MSA. The MSA taxonomy was developed by the US Office of Management and Budget
and is used by the US Census Bureau and other government agencies for statistical
and data analysis purposes [40].

Dependent variable

The dependent variable for this analysis was consumption of at least 5 daily servings
of combined fruits and vegetables. This was a calculated variable derived from survey
participant responses to several questions asked by the interviewer administering
the survey (see Table 1). Combined fruits and vegetables was chosen as the measure because in the US, fruits
such as avocados, tomatoes, corn, peppers, eggplant, squash, and green beans are often
misclassified as vegetables when they are in fact fruit. By combining fruits and vegetables
we overcome these common misclassifications. Using the measure of a combined five
or more servings of fruits and vegetables is consistent with the measurement of fruit
and vegetable consumption used in some earlier research [7,45]. Furthermore, low fruit and vegetable consumption has been defined by the World Health
Organization panel on diet, nutrition, and prevention of chronic diseases as consuming
fewer than five servings of fruits and/or vegetables daily [45].

Covariates

Additionally, a number of covariates were included in the analyses. The mix of covariates
chosen for inclusion in the analyses included demographic variables associated with
social determinants of health, health services variables associated with receipt of
or seeking health care, and health status/health condition variables. The demographic
covariates were sex, race and ethnicity, age, education, marital status, children
in household and household income. The health services covariates were health insurance
status, having a personal physician, timing of last routine medical check-up, and
deferment of medical care because of cost. The health status/health condition covariates
were self-defined health status, body mass index (BMI), and physical activity. A number
of these covariates were re-coded from their original formulation for use in this
analysis. Table 1 summarizes the original survey questions and response categories with the re-coded
response categories. Missing data were not included in the data analysis.

Age and number of children in the household were the only continuous variables re-coded
as categorical ones. The variables education, marital status, household income, have
a personal physician, timing of last routine medical check-up, and self-defined health
status all had multiple categories that were collapsed into fewer categories for analysis.
Race and ethnicity, BMI categories, and physical activity were all calculated variables
derived from the responses to several survey questions (see Table 1 for greater detail).

Race and ethnicity was calculated from participant responses to two separate survey
questions---one regarding race and the other regarding Latino/Hispanic ethnicity.
Combining the responses to these two questions allowed for the derivation of the race
and ethnicity variable used here. All race/ethnicity categories were computed as mutually
exclusive entities. For example all respondents coded as Caucasian chose white as
their racial classification, likewise black for African American, etc. If a respondent
identified themselves as Hispanic, they were classified by that ethnic category regardless
of any additional racial classification.

BMI was calculated from two survey questions, the first asking the respondents height
in feet and inches and the second their weight in pounds. The BMI formula BMI = weight
in pounds × 703/height in inches2 was then used to calculate BMI and code the resultant number into one of three categories:
BMI < 25 (neither overweight nor obese), BMI

>

25 - < 30 (overweight), and BMI

>

30 (obese).

Level of physical activity was calculated by combining other variables assessing physical
activity level by: 1) whether or not a person was getting recommended levels of moderate
physical activity, and 2) whether or not a person was getting recommended levels of
vigorous physical activity. People who reported getting recommended levels of either
moderate or vigorous physical activity were coded as getting at least recommended
levels of moderate physical activity. Recommended levels of moderate physical activity
were defined as moderate-intensity activities such as brisk walking for at least 30
minutes per day, at least five days a week. Respondents getting less than moderate
levels of physical activity were coded as inactive.

Analysis

Bivariate analysis using unadjusted odds ratios and/or contingency table analysis
with a chi square test for statistical significance and multivariate logistic regression
using weighted data and adjusted odds ratios as the test statistic were performed.
The dependent variable for these analyses was rural US adults consuming at least five
daily servings of combined fruits and vegetables. Additionally, ArcView version 10.0
(ESRI, Redlands, CA) was used to map the prevalence differences by State between rural
and non-rural adults consuming at least five or more daily servings of fruits and/or
vegetables. For this calculation and mapping effort the prevalence of rural adults
consuming at least five daily servings of fruits and vegetables by state was compared
to the prevalence of their non-rural counterparts in the same state. States were color
coded on the map to show if the rural in comparison to non-rural adult population
of a state had a higher prevalence or a lower/smaller prevalence of consuming at least
5 daily servings of combined fruits and vegetables.

For all statistical analyses, alpha was set at p < 0.05. Statistical Package for Social
Scientists (SPSS, IBM, Chicago, IL) version 19.0 was used to complete all statistical
analyses performed for this study. Human subject approval was sought and received
from Essentia Health’s IRB as well as the University of Illinois, College of Medicine
at Rockford’s IRB.

Results

Descriptive analysis

For our study, a single year of data for the year 2009 of non-institutionalized US
adults (weighted n = 219,479,823) were analyzed. From the 2009 dataset, a weighted
52,259,789 US adults were identified as consuming at least 5 servings of fruits and
vegetables daily of which 8,983,840 were identified as living in rural locales. Bivariate
analysis revealed that in comparison to US non-rural adults US rural adults were less
likely to consume five or more servings of fruits and vegetables (OR = 1.161, 95%
CI 1.160-1.162) (not shown on table). Table 2 displays additional comparative data for US non-rural and rural adults regardless
of daily consumption of fruits and vegetables. Most notably higher proportions of
rural adults when compared to non-rural ones were: Caucasian, older (

>

65 years of age), heavier (BMI

>

30), less educated (college graduation), poorer (household income < $35,000), married
or living with a partner, and without health insurance. Further, a higher proportion
of rural vs. non-rural adults: did not have children living at home, had not had a
routine medical check-up in the past 12 months, and self-defined their health as fair
to poor rather than good to excellent.

Bivariate analysis

Table 3 displays the results of a bivariate analysis for US adults consuming at least five
servings of fruits and vegetables daily. As measured by either odds ratio or chi square,
all of the covariates in this bivariate analysis yielded a statistically significant
relationship with the dependent variable of consuming at least five daily servings
of fruits and vegetables. As a result all of the covariates were entered into the
multivariate logistic regression model.

Logistic regression analysis

Table 4 displays the results of the multivariate analysis preformed. Consumption of at least
five daily servings of fruits and vegetables was the dependent variable for the model
that included only rural adults. The logistic regression analysis revealed that rural
adults whose daily consumption of fruits and vegetables included at least five servings
were more likely to be: female rather than male; African American, Hispanic or multiracial/other
rather than Caucasian; married or living with a partner rather than single; living
in a household without children; living in a household whose annual income is at least
$35,000 compared to an income than less than $35,000; and getting at least moderate
physical activity rather than being inactive. Rural adults consuming five or more
servings of vegetables daily were also more likely to have: a BMI of <25 or a BMI
of 25 to <30 rather than

>

30; have a personal physician; have had a routine medical exam in the past 12 months;
and self-define their health as good to excellent rather than fair to poor. Rural
adults consuming at least five daily servings of fruits and vegetables were also more
likely to have deferred medical care because of cost.

Rural adults consuming at least five daily servings of fruits and vegetables were
approximately 33% less likely to be younger (18–34 years or 35–64 years) than older
(65 or older). They also were 35.3% to 47.3% less likely of being educated beyond
high school (have less than a high school education or being a high school graduate)
than being a college graduate.

Geographic analysis

Table 5 displays prevalence of rural and non-rural adults consuming five or more daily servings
of fruits and vegetables by State. Weighted data were used to calculate the prevalences
using BRFSS. Also displayed in Table 5 are the standardized percent differences between the prevalences of rural and non-rural
adults consuming five or more daily servings of fruits and vegetables by state. The
state prevalences for rural adults ranged from a low of 13.88% in Oklahoma to a high
of 28.74 % in Vermont. For non-rural adults the prevalences ranged from a low of 14.44%
in Oklahoma to a high of 28.27% in Maine.

Table 5.Prevalence of Rural and Non-Rural Adults Consuming Five or More Daily Servings of
Fruits and Vegetables 2009 BRFSS Data and 2007 USDA Census Data

The differences in prevalences of fruit and vegetable consumption are presented in
Figure 1 with states color coded as having either a higher prevalence (light shade) or a lower
prevalence (dark shade) of fruit and vegetable consumption for rural adults in comparison
to non-rural adults. Thirty-seven states had lower a prevalence of rural adults consuming
at least five daily servings of fruits and vegetables and 11 States a higher prevalence
of rural adults consuming at least five daily servings of fruits and vegetables. In
two States (New Jersey and Rhode Island) no data on the fruit and vegetable consumption
of rural adults were available.

Figure 1.Prevalence of Rural US Adults Consuming at Least Five Daily Servings of Fruits and
Vegetables Compared to Non-Rural Adults 2009 BRFSS Data.

Of the 11 states with a higher prevalence of rural adults consuming at least five
daily servings of fruits and vegetables when compared to the non-rural adult population,
only one State, Hawaii, was ranked in the top 10 states for fruit and vegetable production.
An additional state, Arizona, ranked in the top 20 of fruit and vegetable producing
States.

Discussion

Chronic disease accounts for about 75% of the health care costs in the United Sates
and several studies document the benefits of a healthy diet for weight control, and
for illnesses such as diabetes, cardiovascular disease and certain types of cancer
[3-6,47]. Consuming at least five daily servings of fruits and vegetables are considered an
essential part of an overall healthy balanced diet [2]. Our study found that less than 1 in 4 rural US adults consumed five or more servings
of fruits and vegetables, a result similar to previous research [48], and a proportion that falls dramatically short of the targets set by HP 2010. Our
results also revealed that compared to non-rural adults, a smaller proportion of rural
adults reported consuming five servings of combined fruits and vegetables. The findings
reported here underscore the continued need for developing targeted interventions
that effectively result in healthier dietary choices while addressing possible issues
of the availability and accessibility of healthy foods such as fresh fruits and vegetables.

While it may be ironic that rural adults, who live where fruits and vegetables grow,
were less likely to consume at least five daily servings it is not necessarily unexpected
[48-55]. The importance of community environment as a contributor for individuals adopting
a healthy lifestyle, including the availability of low cost health food choices, is
increasingly being recognized [50]. Although rural communities produce fruits and vegetables, they typically have fewer
stores that offer a wide selection of healthy lower-cost food than non-rural communities
[49] and rural residents are more likely to live in a food deserts [56,57]. Since approximately 20% of the US population lives in rural settings [51] strategies aimed at improving access to healthy foods for rural residents could yield
significant health benefits. Furthermore, an additional related issue is the ability
and/or willingness of rural residents to travel greater distances to food stores where
a greater availability of and choices for fruits and vegetables might be found [31].

In addition to environmental access issues, rural residents are typically poorer than
their non-rural counterparts and affordability is likely an important contributing
factor to fewer rural residents consuming greater amounts of fruits and vegetables.
Our results indicate that a higher proportion of rural residents earning less than
$35,000 did not consume at least five servings of fruits and vegetables when compared
to their non-rural counterparts. Food costs correlate to store type and food tends
to be less expensive in larger supermarkets than smaller markets or convenience stores.
These higher priced food outlets may be the only local and convenient food source
for some rural communities. In addition to a convenience factor, transportation costs
may be a barrier to purchasing less expensive healthier food that might be available
in a nearby community.

Our findings also reveal several differences in the consumption of fruits and vegetables
by characteristics such as gender, age, education, race/ethnicity, physical activity
and reported health status. Similar to other studies [22-29], this study found that in rural populations women and those with more education were
more likely to consume five or more daily servings of fruits and vegetables. Likewise
rural adults over age 65 were more likely to eat at least five servings of fruits
and vegetables daily. Data regarding race and ethnicity from previous studies are
mixed. In some studies, Caucasians consumed more fruits and vegetables than African
Americans while other studies using national data demonstrated the converse [52-55]. Our study found that Caucasians were less likely to consume five servings of fruits
and vegetables and that the difference was greater for Caucasians living in rural
settings, even though they tended to be better educated and have higher income levels
than rural non-Caucasians (combined African Americans, Hispanics, other/Multiracial).
The reasons for this difference are not clear and further study to confirm this finding
and to understand the reasons why may be helpful in tailoring interventions to improve
dietary choices among rural residents.

Those rural residents engaging in at least moderate physical activity and with a lower
BMI were also more likely to consume five servings of fruits and vegetables. While
physical activity and weight do not directly affect diet choices, our findings add
to the body of knowledge that unhealthy lifestyles choices tend to coexist or cluster
among individuals [52] just as healthy lifestyle choices do.

Finally, of interest is the distribution of fruit and vegetable consumption by rural
and non-rural adults by state. This distribution indicated that in only 11 states
did rural adults have a higher prevalence of consuming five or more daily servings
of fruits and vegetables than non-rural adults. The reason for this prevalence difference
is unclear especially since of those 11 states only one, Hawaii, ranked as a top ten
US State for fruit and vegetable production. This finding does suggest the need for
further investigation---specifically to answer the question, are there differences
between the rural populations in the states where there is a high prevalence of rural
adults who are consuming at least five daily servings of fruits and vegetables and
those states where such is not occurring? This might provide insight into the role
that community environment plays in diets and for what strategies for improving diets
might be best suited to a specific rural settings. Also issues such as climate might
be more important for rural residents who may be more likely to grow their own food
(e.g., vegetables) and could account for some differences among states.

Limitations

Several potential limitations to this study should be noted. First, the survey is
based on telephone derived data and may be skewed because those who could not be reached
by phone could not participate in the survey. For example, persons of lower socioeconomic
status may have been excluded because of poorer phone access. However, the fact that
the vast majority of US residents live in households with telephones minimizes this
bias. Furthermore, US cell phone numbers are now included in the pool of phones contacted
for the survey. In addition, study strength is the use of a large multi-state database
that includes a robust sample of rural residents weighted to reflect the demographics
of rural and non-rural US populations.

A second limitation is that the survey used close-ended questions, which limit a responder’s
options to fully explain response choices. However, while a different question format
may have yielded different results, the survey questions were worded such that the
answer choices covered a wide range of response possibilities. A third and related
limitation is that the answers are self-reported, which introduces the possibility
of recall bias on the part of the survey participants.

Fourthly, the question asking respondents about the number of servings of vegetables
is somewhat ambiguous and may have led to an under-reporting of the number of servings
of vegetables consumed. For instance no refined measure of consumption was included
hence eating vegetables at both lunch and dinner may in actuality constitute more
than two servings depending upon the amount of vegetables consumed. Furthermore, the
questions did not specifically address vegetables in foods such as stews or soups.
However, there is no reason to suspect that there would be reporting differences between
rural and non-rural populations suggesting the data can yield meaningful comparisons.

A fifth potential bias resulted from the languages of the survey – English and Spanish.
Individuals who did not speak English or Spanish were excluded from this survey. Not
all US residents speak the two languages of this survey as a result those adults from
other cultures who do not speak either English or Spanish and who have vegetable rich
(e.g., Chinese) or fruit and vegetable rich (e.g., Mediterranean) diets may have been
excluded and as a result the aggregated data may not be representative of actual consumption
by all adults who are residing in the United States.

Finally, in the US, no standard definition exists for rural. In the BRFSS data used
in this study, MSA was the only possible definition for rural. The main weakness of
the MSA definition is that it does not differentiate well between nonmetropolitan
or rural counties. The strengths, however, of the MSA definition are that it is stable
over time and it is familiar to policy makers.

Conclusion

In conclusion, most Americans do not eat the recommended number of servings of fruits
and vegetables. However, rural residents appear at greater risk for not making healthy
dietary choices. Successfully improving the dietary patterns of Americans will need
to incorporate the environmental context in which people live. The enhanced understanding
of fruit and vegetable consumption provided from the research reported on here should
prove useful to those seeking to lessen the disparity or inequity between rural and
non-rural adults in regard to adequate fruit and vegetable consumption. Our findings
should be helpful for public health practitioners interested in developing population-level
prevention-focused interventions aimed at improving the diets and health of rural
Americans and in understanding the importance place plays in the creation of health
inequities and the need for developing targeted public health interventions.

Misc

An earlier draft of this paper was presented to the annual meeting of the National
Rural Health Association, 3–6 May 2011, Austin Texas

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

MNL, LFC, MSL all made substantial contributions to conception and design of the manuscript.
MNL was responsible for the acquisition of the data used and the analysis of data.
MNL, LFC, MSL were equally involved in interpreting the data, drafting the manuscript
and revising it critically for important intellectual content. MNL, LFC, MSL have
given final approval of the version to be published. All authors read and approved
the final manuscript.

Acknowledgements

No acknowledgements. There was no external funding for this research study.

Funding disclosure

We have no funding to disclose. This research was conducted without funding.

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